High Alert Medications

Basic Medication Safety (BMS) Certification Course

King Saud bin Abdulaziz University for Health Sciences, Ministry
of National Guard – Health Affairs
 Learning Objectives

 Define and identify High Alert Medications

 Share our experiences / reporting

 Identify common risks

 Outline strategies to improve and minimize risks

 Reinforce policy & procedures

 High Alert Medications

Medications that pose an

risk of causing significant

to patients if used in

APP 1429-02 Look-Alike, Sound-Alike & High Alert Medication

 Top 10 Medications Reported as MedMarx 2008 High Alert Meds with
Causing Harm Harm Score E and Above
Accounted for 199 / 465
# of reports 300
60 (43%) Harmful Incidents.
(ISMP Canada; 2001-2005) 250
50
40 200

30 150

20 100
10
50
0
0
 Reported Medication Errors / Near Misses for
Top Four High Alert Medications

2015, 2016 and 2017 - Central Region (KAMC) Total HAM:

 2015 = 527
 2016 = 814
250  2017 = 814

200

150
2015
100 2016
2017
50

0
Antithrombotic Opiates/Narcotic Chemotherapeutic Insulin
Agents Agents Agents
 NCCMERP Categorizing Medication Errors for All
High Alert Medication Events

2015, 2016 and 2017 - Central Region (KAMC)

300
274

247 248
250
209
200 187
174

142
2015
150 133 135
2016
2017
100

46
50 40 38
29 37 35
17 11
9 3 4
0 1 2 0 0 1 0 0 1 0 1 0 0
0
A B C D E F G H I NA <N/S>
 Half of Preventable ADEs involve:

DRUG TOO MUCH LEADS TO:

Opiates Respiratory depression
Insulin Hypoglycemia
Anticoagulants Bleeding

U$3.5 billion is spent annually on extra medical costs of ADEs

Winterstein, A., Hatton, R., Gonzalez-Rothi, R., Johns, T., & Segal, R. (2002). Identifying clinically significant preventable adverse drug events
through a hospital’s database of adverse drug reaction reports. Am. J. Health Syst. Pharm., 59(18), 1742–1749. Retrieved from

Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National
Academies Press 2006.
 Case:

 44 year old male

 History of PE on Warfarin

 Admitted for bilateral hydronephrosis, with acute renal failure for bilateral
nephrostomy tube placement
 Post-nephrostomy tube the anticoagulation was resumed with
Enoxaparin 120 mg q 12 hr in the setting of severely compromised renal
function

 Patient was transferred to ICU with clinical picture of shock, which turned
to be hemorrhagic, complicated by multi-organ failure and death

 Ultrasound of abdomen showed evidence of intra-abdominal collection

 Anticoagulants

Percentage of Reported High Alert Medication Events

 22% during 2017 at KAMC-Riyadh
 24% during 2016 at KAMC-Riyadh

Common Risks
 Lack of standardization in names and packs
 Complicated dosing regimens
 Low Molecular Weight Heparin (LMWH) syringe designed
for adults only
 Anticoagulants

Common Strategies
 Standardize labels, packaging
 Protected Standard Concentration
 Anticoagulation Services
 Counseling
 Use protocols / smart pumps
 Individualized monitoring and handoffs
 Medication Reconciliation
 Improved Information and Counselling for Patients
 At start of therapy (prescription)
 On hospital discharge
 At the first anticoagulant clinic appointment
 When necessary throughout course of therapy
 Opiates

Percentage of Reported High Alert Medication Events

 24% during 2017 at KAMC – Riyadh
 23% during 2016 at KAMC – Riyadh

Common Risks
 LASA (Morphine and HYDROmorphone)
 Lack of leading zero
 Ordered .8 mg, patient received 8 mg Morphine
 Bolus dose, failing to re-program maintenance dose
 Different rates and concentrations
 Improper disposable of Transdermal Patches
 Opiates

Common Strategies
 Differentiate products
 Use TALL man lettering
 Use conversion tables
 Time Out prior to intrathecal injection and ONLY intrathecal
meds will be in the procedure area
 Education for staff regarding PCA
 Develop a quick reference sheet on PCA
 Implement protocols for the use of PCA and other opioids
 Proper patient education
 Chemotherapy

Percentage of Reported High Alert Medication Events

 18 % during 2017 at KAMC-Riyadh
 15 % during 2016 at KAMC-Riyadh

Cases
Drug Error and Outcome

Methotrexate Administering daily instead of weekly

(approximately 25 fatalities reported)
VinCRIStine Accidental Intrathecal administration - Fatal
Lomustine Oral agent administered daily instead of
every 6 weeks, hospitalization and death
CARBOplatin CISplatin administered at dose intensity
and CISplatin appropriate for CARBOplatin, fatal outcome
 Chemotherapy

Common Risks
 Miscommunication
 Total course (or cycle) dose given every day
 Substantial distance between Pharmacy and patient treatment
area (lack of communication)
 Lack of health care information (labs, BSA)
 Excessive interruptions
 LASA / packaging
 Lack of protocols and education
 Route of administration: Intravenous vs. Intrathecal
 Chemotherapy

Common Strategies
 Drugs are ONLY stored in Pharmacy
 Standard chemotherapy order sets
 Orders must be signed by an authorized Consultant
 Double check against actual order / protocol
 No abbreviations / error-prone abbreviations
 Avoid excessive precision (round off 919.57)
 Non-Oncology indications: Order sets have dosing, route
safeguards programmed in them
 Chemotherapy

Common Strategies: Cont.

 Use of personal protective equipment to reduce employee
exposure to hazards
 Dispense VinCRIStine (and other vinca alkaloids) in a minibag of
a compatible solution and not in a syringe
 Weekly dosage regimen default for oral Methotrexate in
electronic systems when medication orders are entered.
 Body Surface Area dosing (mg / m2), when applicable mg / kg
 Use updated lab information
 Patient / caregiver education
 Communication
 Insulin

Percentage of Reported High Alert Medication Events

 8% during 2017 at KAMC Riyadh
 13% during 2016 at KAMC Riyadh

Common Risks
 Look-Alike Vials
 Use of “U” or “IU”
 Incorrect dose / rate
 Lack of dose checking
 Insulin

Common Strategies
 Spell out “Units” and “Numbers”
 Smart pump / double-check
 Protected standard concentration of Adults
 Order sets for
 Perioperative Management of a Diabetic Patient’
 Regular
 Insulin IV Infusion Scale in Intensive Care Department
 Insulin Infusion Protocol in Cardiac Sciences
 Basal-Bolus-Corrective Subcutaneous Insulin Protocol in Internal
Medicine
 Store separately / labels
 Concentrated Electrolytes

Common Risks
 Concentrated Electrolytes

Common Strategies
 Stored in Red Bins with Lids
 Patient care areas: Stored in ADC
locked Lidded
 Crash Cart / Black Box (as
applicable)
 Auxiliary label “High Alert / Conc.
Electrolyte: Must Be Diluted”
 Standardized medication labels

APP 1433-18: Concentrated Electrolytes

 Concentrated Electrolytes

Common Strategies: Cont.

 Storage of Concentrated Electrolytes Outside of Pharmacy is Limited to
(as applicable)

Concentrated Clinical Justification for Location by Clinical Care

Quantity
Electrolyte Concentrated Electrolyte Area
Magnesium sulfate • Cardioplegia • Crash Carts Determined
4 mEq/mL or higher • Eclampsia • Cardiac / Liver OR by Region
concentration • Torsades de pointes • Emergency Medical
Services (EMS)
• Main OR
• Surgical Tower OR
Potassium chloride • Cardioplegia • Cardiac / Liver OR Determined
2 mEq / mL or higher • Main OR by Region
concentration
General Strategies For High Alert
Medications
 General Strategies for High Alert Medications

 TALLman lettering
 ‘LASA’ on label, when applicable
 “High Alert” on storage label
 High Alert Medications must be stored in Red Bins using
Standardized Medication Labels
 Medication which must be stored in Red Bins with Lids
 Concentrated Electrolytes
 Parenteral Skeletal Muscle Relaxants (Paralyzing agents)
 Patient care areas: Stored in ADC locked Lidded
 CPOE with clinical decision support, providing immediate warnings
if unsafe orders are entered
 General Strategies for High Alert Medications

 Use of smart infusion pumps with dose

checking software enabled
 Order sets
 Independent Double-Check (IDC)
Procedure in which two healthcare
professionals separately check (alone and
apart from each other, then compare
results) each component of prescribing, Done without
distractions
transcribing, dispensing and verifying the
medication before administering to the
patient
 Dispensing
 Verifying at time of administration
General Strategies for High Alert Medications

APP 1429-02: Look-Alike/Sound-Alike And High Alert Medications, January- Appendix D

General Strategies for High Alert Medications

APP 1429-02: Look-Alike/Sound-Alike And High Alert Medications, April 2017 - Appendix C
Information available at One Stop Resource
Alerts Advisories at HIS-CPR

Alerts Advisories
 Max
 Interactions
 Allergies